For Dr Anthony D Harries, Senior Advisor and Director, Department of Research, at The Union, diabetes is a more serious problem to control than TB, more so because of the large number of people (400 million) suffering from it globally and 10 million getting added to this pool every year. On the other hand around 9-10 million new people get TB every year. But then TB can be cured but not DM. So once you have DM, you probably have it for life. It can be controlled by life style changes. Lifestyle changes involve doing regular physical exercise and eating the right type of food. All this is not easy to do. Moreover it is not only about individuals changing, but the whole food and beverage industry also plays a crucial role in it.

Dr Anil Kapur, Chairman of WDF, echoes similar thoughts--“Diabetes is more difficult to prevent as well as to control for the simple reason that it is much more prolonged and involves life long control. On the other hand TB though a serious disease, the treatment duration is shorter and prevention options are more in the public health domain. Preventive actions for diabetes are more in personal hands and it requires a lot of individual effort to keep on living a life that is healthy in an environment that is unhealthy”.

Interventions to improve prevention
Dr Kapur feels that for DM patients the key to prevention is good diabetes control. Excess risk from diabetes for TB is emerging due to poor diabetes control. Secondly, diabetes clinics should be aware of the enhanced risk in DM patients of getting TB. These clinics should ensure that there is facility for infection control within the clinics, so that people with DM are not exposed to those patients who have TB as well, and are sitting in the same clinic. DM patients visit clinics/hospitals much more often than other patients, and hence are more likely to be exposed to infections like TB. For TB patients, improving their living conditions is important—properly ventilated houses and good nutrition. For both of them early diagnosis and proper treatment will cut the cycle of transmission.

Bidirectional screening helps in early diagnosis of DM in TB patients and vice versa. While getting consent of TB patients for DM screening may not pose any problem, but asking a DM patient to screen for TB may not be that easy, given the social stigma attached with TB. But Dr Kapur feels bi-directional screening is not that complicated if handled carefully and done the right way.

“We can tell the DM patients that we need to check their nerves, eyes, kidneys and lungs–without using the word TB. They should be made aware that they are at risk of other infections, particularly TB and so should not hesitate to come if they get any symptom of TB like prolonged cough, fever, night sweat, weight loss etc. Unless the problem hits us in the eye, we turn a blind eye to it - neither the government nor healthcare professionals take serious notice of it”.

Dr Harries takes the example of India where bi-directional screening, implemented with government’s support in 2012, was found to work well in pilot studies under routine conditions. But there were problems later on, more so because TB is perhaps not perceived as that much of an issue by diabetes specialists, feels Dr Harries.

“For them diabetic foot, gangrene, neuropathy, CVD, etc are bigger problems to concentrate upon in case of DM patients, but not TB. They may be correct in that sense. But then while all these problems affect the individual only, TB not only affects the individual, but being an infectious disease, it can be transmitted to others too. This should raise the importance of TB in the eyes of diabetologists. India has a good national TB control programme, so there is no reason why DM patients diagnosed with TB cannot be fed into that system. As it is we miss a large number of TB cases and if we screen those coming for DM treatment for TB, we might be able to decrease that pool of undiagnosed TB cases”.

In the opinion of Dr Harries, at the health system level we have to make sure that TB patients are screened for DM, and in DM clinics doctors pay enough importance to screen patients for TB. At the ground level people need to be made more aware and knowledgeable about this problem. The urban poor at high risk of both DM and TB, and yet very few people on the street know about the connect between them. Various media platforms can help by disseminating correct information and health messages endorsed by the medical fraternity as well as taking help from celebrities to advertise for the cause.

There is need not only to do bi-directional screening, but do bi-directional thinking and multi-strategic planning, with various stakeholders - policy makers, health professionals, government officials, advocates, civil society groups, researchers and businesses - for a multi-pronged attack to vanquish this double faced demon.